Global NCD policy implementation stalls in the modern era
Authors: Sandeep P Kishore
Journal: The Lancet Global Health (2023)

How has policy implementation for non-communicable diseases (NCDs), the leading drivers of morbidity and mortality globally, fared in the modern era? What are the associations of unhealthy commodity consumption and corporate influence with national policy implementation? Which geopolitical areas have high policy implementation, and more importantly, which areas are of concern? And how did the onset of the COVID-19 pandemic intersect with national NCD policy setting? In this issue of The Lancet Global Health, Luke Allen and colleagues1Allen LN Wigley S Holmer H Barlow P Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countries.Lancet Glob Health. 2023; 11: e525-e533Summary Full Text Full Text PDF Scopus (2) Google Scholar build on their previous work in putting forward key accountability metrics related to policy implementation,2Allen LN Nicholson BD Yeung BYT Goiana-da-Silva F Implementation of non-communicable disease policies: a geopolitical analysis of 151 countries.Lancet Glob Health. 2020; 8: e50-e58Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar to aid civil society and governments in answering these fundamental questions, as part of efforts in working towards globally agreed goals (eg, reducing NCD-related premature mortality by 33% by 2030).3Kishore SP Majumdar UB Learning from progress: global NCD policy implementation at national level.Lancet Glob Health. 2020; 8: e4-e5Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar Once again, Allen and colleagues focus on so-called best buy policies derived by WHO that span the prevention and control of NCDs. The 19 policies in total address the spread and scale of commercial, health-harming risks, and include policies on tobacco, alcohol, unhealthy food, sugar-sweetened beverages, child marketing, national NCD plans, and medication access. Allen and colleagues use WHO NCD progress monitor surveys from 2015, 2017, 2019, and 2021 to develop a scorable profile and assess variance between geographical and geopolitical groupings across 194 countries for the 19 WHO best buys. They also assess the effect of conflicts of financial interest, using a Corporate Financial Influence Index (CFII), on policy implementation, and how changes in consumption were linked to policy implementation. The findings are both striking and sobering in four ways. First, based on mean total policy implementation score for all 194 countries, the total policy implementation for the NCD best buys stalled at 47·8% in 2021; at the same level as before the pandemic in 2019. This finding indicates that, on average, less than half of the 19 best buy interventions are being implemented. As noted by Allen and colleagues, this work captured data at the onset of COVID-19. As such, it should not be taken to imply medium-term or long-term consequences of the pandemic itself. The particular targets for which policy implementation has stalled are particularly notable. Decreases in global implementation compared with 2019 were found for policies on alcohol, breastmilk substitutes, physical activity campaigns, risk factor surveys, and the setting of national NCD plans and targets. The study found that six of the seven policies with lowest implementation in both 2019 and 2021 were related to restrictions around unhealthy commodities including tobacco, alcohol, and unhealthy food. Second, there continues to be wide geographic variation in mean implementation scores. By regional, geographical, and geopolitical groupings, mean scores in 2014–21 were lowest in the Africa region, low-income countries, and fragile and conflict-affected states. Mean implementation scores were highest in the Europe region, high-income countries, former Soviet states, and in countries of the Organisation for Economic Cooperation and Development and the EU. Between 2019 and 2021, the largest decreases in implementation score were in the South-East Asia region and in small island developing states. Third, the findings indicate that governments are slow to respond to the spread and scale of unhealthy commodities, including at the start of the COVID-19 pandemic. Since 2020, an increase in per-capita sales of unhealthy commodities (in this case, beer, wine, sugar, sweeteners, and baked goods) was concentrated in low-income and middle-income countries, whereas per-capita sales of these commodities decreased in high-income countries. Crucially, the predicted probability of policy responses were weakly associated or not associated with the increases in consumption. Finally, using recent data on corporate activities, the authors computed CFII for each WHO member state, and by various regional groupings including geopolitical bloc and income group. In correlation analysis, countries with high corporate financial influence had the lowest levels of policy implementation (Pearson's r –0·49, 95% CI –0·59 to –0·36). Additionally, they found CFII to explain 23·7% of the variance in overall NCD implementation scores in 2021. The work has two important applications. First, subnational and national civil society organisations need to be strengthened to foster accountability. The accountability of governments on their efforts towards NCD-related policies, including voluntary targets, remains mixed, if not persistently poor. If NCDs, including both the causes and consequences, represent the social justice of our time, we are clearly falling behind on global commitments. Even in settings where policies have been set, the final implementation gap has not been closed—as in the case of access and affordability of critical essential medicines for the prevention of cardiovascular disease in community settings.4Zhu JZ Manne-Goehler J Agarwal A et al.Medication use for cardiovascular disease prevention in 40 low- and middle-income countries.J Am Coll Cardiol. 2023; 81: 620-622Crossref PubMed Scopus (3) Google Scholar However, despite the recent data, there is some hope. Since 2014, implementation scores of national policies have improved in all geopolitical blocs. The evidence is clear for supporting independent efforts on civil society monitoring, and making an investment case for NCDs is a must, as is engaging a new generation of citizen scientists on policy implementation science. Regarding the second application, the findings suggest that political equality is central to the advancement of health as a fundamental right. Although this study could only identify associations and not causal pathways, Allen and colleagues highlight how the countries with the highest scores for corporate financial influence had weak or no democratic governance and the lowest levels of NCD policy implementation. Therefore, ensuring that health-harming industries do not exert influence on global or national policy setting—including in the possible revision of the policies (set out in appendix 3 of WHO's global NCD action plan6WHOPolitical declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases, and mental health.https://apps.who.int/gb/ebwha/pdf_files/EB152/B152_6-en.pdf#page=13Date: Jan 10, 2023Date accessed: February 28, 2023Google Scholar)—is vital, and a crucial role of civil society now more than ever. I declare no competing interests. Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countriesNCD policy implementation has stagnated. Progress in the implementation of some policies is matched by decreased implementation of others, particularly those related to unhealthy commodities. To prevent NCDs and their consequences, and attain the Sustainable Development Goals, the rate of NCD policy adoption must be substantially and urgently increased before the next NCD progress monitor and UN high-level meeting on NCDs in 2024. Full-Text PDF Open Access